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In 1980-81, 43 babies died at Toronto's Hospital for Sick Children from a supposed digoxin overdose. Serial murder was suspected, leading to the arrest of nurse Susan Nelles. In order to clear Nelles's name, an investigation was launched to find an alternate explanation.

No one on the Grange Royal Commission of Inquiry had expertise in diagnosis. The post-mortem diagnosis of digoxin poisoning was based on a single biochemical test without knowledge of the normal values. Gavin Hamilton's extensive research shows that a toxin found in natural rubber, a digoxin-like substance, might well have been the culprit in the babies' deaths. He clearly demonstrates that explanations other than serial murder account for the cluster of infant deaths at HSC.

What can be learned from this black stain on Canada's judicial system? One lesson certainly stands out: we can't ever again allow a group of unqualified amateur diagnosticians make life-and-death decisions about such important matters as potential serial murders.

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